Static palpation ain't easy: Evaluating palpation precision using a topographical map of the lumbar spine as a reference.

INTRODUCTION: Clinicians commonly use manual therapy to treat low back pain by palpating the spine to identify the spinous processes. This study aims to evaluate the ability of experienced clinicians to consistently locate the spinous processes from S1 to T12 through palpation. The results will be compared to topographical data representing the lumbar lordosis at baseline and four follow-up time points. MATERIALS AND METHODS: In a prior prospective randomized trial, experienced clinicians used palpation to locate the lumbar spinous processes (S1-T12) and then digitized these locations in three-dimensional space. The same digitizing equipment was then used to continuously collect three-dimensional position data of a wheel that rolled along the back's surface through a trajectory that connected the previously digitized locations of the spinous processes. This process was repeated at 4 days, 1, 4, and 12 weeks. The resulting lordosis trajectories were plotted and aligned using the most anterior point in the lordosis to compare the locations of the spinous processes identified in different trials. This way, spinous palpation points could be compared to surface topography over time. Intra- and interrater reliability and agreement were estimated using intraclass correlations of agreement and Bland-Altman limits of agreement. RESULTS: Five clinicians palpated a total of 119 participants. The results showed a large degree of variation in precision estimates, with a mean total value of 13 mm (95%CI = 11;15). This precision error was consistent across all time points. The smallest precision error was found at L5, followed by S1 File, after which the error increased superiorly. Intra- and interrater reliability was poor to moderate. CONCLUSIONS: Comparison of palpation results to a topographic standard representing the lumbar lordosis is a new approach for evaluating palpation. Our results confirm the results of prior studies that find palpation of lumbar spinous processes imprecise, even for experienced clinicians.

Exploring the Impact of In Basket Metrics on the Adoption of a New Electronic Health Record System Among Specialists in a Tertiary Hospital in Alberta: Descriptive Study.

BACKGROUND: Health care organizations implement electronic health record (EHR) systems with the expectation of improved patient care and enhanced provider performance. However, while these technologies hold the potential to create improved care and system efficiencies, they can also lead to unintended negative consequences, such as patient safety issues, communication problems, and provider burnout. OBJECTIVE: This study aims to document metrics related to the In Basket communication hub (time in In Basket per day, time in In Basket per appointment, In Basket messages received per day, and turnaround time) of the EHR system implemented by Alberta Health Services, the province-wide health delivery system called Connect Care (Epic Systems). The objective was to identify how a newly implemented EHR system was used, the timing of its use, and the duration of use specifically related to In Basket activities. METHODS: A descriptive study was conducted. Due to the diversity of specialties, the providers were grouped into medical and surgical based on previous similar studies. The participants were further subgrouped based on their self-reported clinical full-time equivalent (FTE ) measure. This resulted in 3 subgroups for analysis: medical FTE <0.5, medical FTE >0.5, and surgical (all of whom reported FTE >0.5). The analysis was limited to outpatient clinical interactions and explicitly excluded inpatient activities. RESULTS: A total of 72 participants from 19 different specialties enrolled in this study. The providers had, on average, 8.31 appointments per day during the reporting periods. The providers received, on average, 21.93 messages per day, and they spent 7.61 minutes on average in the time in In Basket per day metric and 1.84 minutes on average in the time in In Basket per appointment metric. The time for the providers to mark messages as done (turnaround time) was on average 11.45 days during the reporting period. Although the surgical group had, on average, approximately twice as many appointments per scheduled day, they spent considerably less connected time (based on almost all time metrics) than the medical group. However, the surgical group took much longer than the medical group to mark messages as done (turnaround time). CONCLUSIONS: We observed a range of patterns with no consistent direction. There does not seem to be evidence of a "learning curve," which would have shown a consistent reduction in time spent on the system over time due to familiarity and experience. While this study does not show how the included metrics could be used as predictors of providers' satisfaction or feelings of burnout, the use trends could be used to start discussions about future Canadian studies needed in this area.

A consensus approach toward the standardization of spinal stiffness measurement using a loaded rolling wheel device: results of a Delphi study.

BACKGROUND: Spinal stiffness assessment has the potential to become an important clinical measure. Various spinal stiffness-testing devices are available to help researchers objectively evaluate the spine and patient complaints. One of these is VerteTrack, a device capable of measuring posteroanterior displacement values over an entire spinal region. This study aimed to develop a best-practice protocol for evaluating spinal stiffness in human participants using VerteTrack. METHODS: Twenty-five individuals with research experience in measuring spinal stiffness, or who were trained in spinal stiffness measurement using the VerteTrack device, were invited to participate in this 3-Round Delphi study. Answers to open-ended questions in Round 1 were thematically analyzed and translated into statements about VerteTrack operation for spinal stiffness measurements. Participants then rated their level of agreement with these statements using a 5-point Likert scale in Rounds 2 and 3. A descriptive statistical analysis was performed. Consensus was achieved when at least 70% of the participants either strongly agreed, agreed, (or strongly disagreed, disagreed) to include a statement in the final protocol. RESULTS: Twenty participants completed Round 1 (80%). All these participants completed Rounds 2 and 3. In total, the pre-defined consensus threshold was reached for 67.2% (123/183) of statements after three rounds of surveys. From this, a best-practice protocol was created. CONCLUSIONS: Using a Delphi approach, a consensus-based protocol for measuring spinal stiffness using the VerteTrack was developed. This standard protocol will help to improve the accuracy, efficiency, and safety of spinal stiffness measurements, facilitate the training of new operators, increase consistency of these measurements in multicenter studies, and provide the synergy and potential for data comparison between spine studies internationally. Although specific to VerteTrack, the resulting standard protocol could be modified for use with other devices designed to collect spinal stiffness measures.

Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization Framework.

Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP). Although generally supported by systematic reviews and practice guidelines, clinical trials evaluating SMT have been characterized by small effect sizes. This study adopts a Multiphase Optimization Strategy framework to examine individual components of an SMT delivery protocol using a single-blind trial with the goal of identifying and optimizing a multicomponent SMT protocol. We enrolled 241 participants with LBP. All participants received 2 SMT treatment sessions in the first week then were randomly assigned additional treatment based on a fully factorial design. The 3 randomized treatment components provided in twice weekly sessions over 3 weeks were multifidus activating exercise, spinal mobilizing exercise, and additional SMT dose. Primary outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (spinal stiffness, multifidus muscle activation) measures assessed at baseline, 1, 4, and 12 weeks. Significant differences were found for the Oswestry index after 12 weeks for participants receiving multifidus activating exercise (mean difference = -3.62, 97.5% CI: -6.89, -0.35; P= .01). There were no additional significant main or interaction effects for other treatment components or different outcome measures. The optimized SMT protocol identified in this study included SMT sessions followed by multifidus activating exercises. PERSPECTIVE: Optimizing the effects of nonpharmacological treatments such as SMT for LBP is challenging due to uncertainty regarding mechanisms and the complexity of multicomponent protocols. This factorial randomized trial examined SMT protocols provided with differing co-interventions with mechanistic and patient-centered outcomes. Patient-centered outcomes were optimized by inclusion of lumbar multifidus strengthening exercises.

Predicting who responds to spinal manipulative therapy using a short-time frame methodology: Results from a 238-participant study.

BACKGROUND: Spinal manipulative therapy (SMT) is among the nonpharmacologic interventions that has been recommended in clinical guidelines for patients with low back pain, however, some patients appear to benefit substantially more from SMT than others. Several investigations have examined potential factors to modify patients' responses prior to SMT application. The objective of this study was to determine if the baseline prediction of SMT responders can be improved through the use of a restricted, non-pragmatic methodology, established variables of responder status, and newly developed physical measures observed to change with SMT. MATERIALS AND METHODS: We conducted a secondary analysis of a prior study that provided two applications of standardized SMT over a period of 1 week. After initial exploratory analysis, principal component analysis and optimal scaling analysis were used to reduce multicollinearity among predictors. A multiple logistic regression model was built using a forward Wald procedure to explore those baseline variables that could predict response status at 1-week reassessment. RESULTS: Two hundred and thirty-eight participants completed the 1-week reassessment (age 40.0± 11.8 years; 59.7% female). Response to treatment was predicted by a model containing the following 8 variables: height, gender, neck or upper back pain, pain frequency in the past 6 months, the STarT Back Tool, patients' expectations about medication and strengthening exercises, and extension status. Our model had a sensitivity of 72.2% (95% CI, 58.1-83.1), specificity of 84.2% (95% CI, 78.0-89.0), a positive likelihood ratio of 4.6 (CI, 3.2-6.7), a negative likelihood ratio of 0.3 (CI, 0.2-0.5), and area under ROC curve, 0.79. CONCLUSION: It is possible to predict response to treatment before application of SMT in low back pain patients. Our model may benefit both patients and clinicians by reducing the time needed to re-evaluate an initial trial of care.

Reliability of a new loaded rolling wheel system for measuring spinal stiffness in asymptomatic participants.

BACKGROUND: Few, if any, patient reported symptoms have been shown to be related to objective measures of spine function. Recently, patient-reported measures of disability following spinal manipulative therapy have been associated with an immediate decrease in spinal stiffness obtained by instrumented L3 indentation. Given this novel relation, we anticipate that stiffness measures obtained from locations in addition to L3 may yield valuable information. As such, our research team has developed a new technique to acquire stiffness data continuously over an entire spinal region. The reliability of stiffness measurements obtained by this new technique has yet to be quantified. METHODS: Continuous stiffness testing employs a weighted roller that moves uninterrupted over the spine while measuring the resulting spinal deflection along a subject-specific, laser-defined trajectory. A volunteer sample of asymptomatic participants were assessed in 2 sessions occurring 1 to 4 days apart, with each session scheduled at the same time of day. Each session consisted of 3 trials each beginning at a baseline of ~ 17 N then progressing to a maximally tolerable load as defined from pre-test familiarization trials (~ 61, 72 or 83 N). Reliability was evaluated with the intraclass correlation coefficient, the standard error of measurement and Bland & Altman analysis. RESULTS: A total of 17 asymptomatic participants (mean age 29.2 +/- 6 years, 53% female) took part in the study. Overall, the within and between-session reliability of lumbar spine stiffness measures at the maximal tolerable load was excellent ranging from 0.95-1.00 and good to excellent ranging from 0.82-0.93, respectively. Trial averaging was found to reduce standard error of measurement by a mean of 35.2% over all measurement conditions compared to a single trial. Bland and Altman plots for agreement in lumbar spine stiffness measurements varied from - 0.3 +/- 1.2 at unloaded condition to - 0.2 +/- 1.2 at loaded condition. Data from two participants were removed due to the development of back pain between two sessions. CONCLUSION: This study introduced a new technique for measuring spinal stiffness over an entire spinal region in asymptomatic human participants. The new technique produced reliable measurements quantifying the load-displacement values for within-session and between-session assessments.

Is there a reliable and invariant set of muscle synergy during isometric biaxial trunk exertion in the sagittal and transverse planes by healthy subjects?

It has been suggested that the central nervous system simplifies muscle control through basic units, called synergies. In this study, we have developed a novel target-matching protocol and used non-negative matrix factorization (NMF) technique to extract trunk muscle synergies and corresponding torque synergies. Isometric torque data at the L5/S1 level and electromyographic patterns of twelve abdominal and back muscles from twelve healthy participants (five females) were simultaneously recorded. Each participant performed a total number of 24 isometric target-matching tasks using 12 different angular directions and 2 levels of uniaxial and biaxial exertions. Within- and between-subject similarities were assessed by considering both the data of different pairs of participants, where the activation coefficients of one participant were used in the NMF analysis of another participant, and the Pearson's correlation coefficients (R) between muscle synergy vectors. The results showed that, for a healthy person, a set of four muscles (overall variance accounted for (VAF) of 97.9 ± 0.53%) and four corresponding torque synergies (overall VAF of 92.2 ± 3.03%) could efficiently decompose the sagittal and transverse torque planes into their main directions. Furthermore, the correlation coefficients were 0.77 ± 0.12, 0.86 ± 0.08, 0.78 ± 0.12, and 0.93 ± 0.04, for all synergies, reflecting the consistency of muscle synergies across participants. Overall, our results suggest that by taking advantage of muscle synergies we could potentially overcome the redundancy inherent to control strategies of the trunk neuromuscular system. In future studies, the synergies identified in patients with low back pain could be compared with those extracted from healthy participants towards various clinical and rehabilitation applications.

The effect of chronic low back pain on trunk accuracy in a multidirectional isometric tracking task.

STUDY DESIGN: A cross-sectional study to quantify trunk motor control during multidirectional isometric tracking tasks. OBJECTIVE: To investigate the effect of chronic low back pain (LBP) on trunk neuromuscular performance while participants performed isometric exertions of trunk muscles to track targets in different angles with various magnitudes. SUMMARY OF BACKGROUND DATA: Tracking tasks especially in multidirectional activities are among the common research methods to quantify human motor control in different conditions. However, little information is available on trunk motor control during these tasks. There is no study investigating trunk accuracy during multidirectional isometric tracking tasks in patients with LBP. MATERIALS AND METHODS: Twelve patients with chronic LBP and 16 asymptomatic participants performed isometric target tracking tasks in 12 different directions with varying magnitude, from 0% to 80% of individual maximum voluntary exertion, in upright standing posture. The tracking system included a moving target object that moved on a straight line in a predefined angle with the rate of 6% maximum voluntary exertion/s. Trunk accuracy was quantified by computing constant error and variable error during each trial. A mixed model repeated measure analysis of variance was conducted to assess statistical analysis. RESULTS: Patients with chronic LBP track the target object with higher error compared with healthy controls across almost all of the target angles (P < 0.01). Trunk accuracy decreased significantly in higher level of exertions (P < 0.01). CONCLUSION: The results provided additional evidence of a change in trunk control strategies in patients with chronic LBP. Decreased accuracy of trunk during isometric tracking tasks especially in higher levels of asymmetric exertions may explain higher risk of low back injuries in these activities. LEVEL OF EVIDENCE: 4.